Sunday, October 30, 2011

Difficult Behaviors Decoded

  Difficult Behaviors Decoded
An expert offers advice for curbing difficult resident behaviors by understanding their causes and reacting in more effective ways.
 October 2011
 Danielle Russo

 Loud screams echo in the hallway. A nurse’s attention shifts from the chart she was working on to the room from which the screams are coming. She runs toward the resident and provides verbal reassurance, coupled with physical comfort of rubbing his arm and shoulder. The screams cease. The nurse walks away and resumes charting when the screams echo again.
This scenario routinely occurs in long term care settings, with many challenging behaviors such as screaming out, aggression, and sometimes hitting. Such behaviors can increase over time, with staff often habituating a behavior-response pattern. The Functions Of BehaviorBehavior is everything that a person does. Waving hello, walking down the street, talking to a neighbor are all behaviors. These behaviors serve as a function for an individual: waving hello to gain the attention of anther person, walking down the street for exercise, and talking to a neighbor for social interaction.  Residents in long term care settings may exhibit maladaptive behaviors such as verbal abuse, physical aggression, elopement, noncompliance, or socially disruptive behaviors for a purpose, a specific function. Determining the function of the behavior will help staff assist the resident in exhibiting positive behavioral repertoires. From an applied behavioral analysis perspective, there are four functions of behavior. The most easily understood function is attention. In the example above, loud screams echo the hallway from a resident. The staff response is to approach and provide physical and verbal comfort. The screams cease when attention is given. The screams reemerge once the staff member has left.  This interactive exchange between the resident and staff has taught the resident that by screaming, he will gain staff attention, and when the screaming stops, the attention stops. This behavior response pattern will increase the likelihood of the behavior of screaming to become more frequent.  The second function of behavior is called escape. Demands placed upon a resident, such as showering, taking medicine, or changing clothes, can be viewed as aversive, which can manifest into verbal abuse or aggression. These behaviors serve as a function to ultimately escape from the desired task.  The most common scenario is when staff are delivering care. A resident may often yell or strike out in an attempt to terminate and “escape” from the activity. If the response from staff is to stop the activity, the resident is more likely to continue to strike out during care to escape. The third function of behavior is tangible. Residents often yell, curse, or strike out at staff when access to a particular tangible item is limited, such as the desire for more food at mealtime.  The last function of behavior is sensory. This occurs when the behavior serves as an automatic reinforcement independent of the environment. The resident’s behavior is self-stimulatory, such as scratching oneself.  Preventing Reinforcement So how can staff effect behavioral change? Well, it could be as obvious as staff giving a directive, or it can be as obscure as fixing a crooked painting on the wall.  While there are many variables that may influence challenging behaviors like these, including genetics, physical limitations, biological needs, and others, what is often not realized is that the environment—in this case, the staff’s reaction to the challenging behavior—plays a vital role in the resident’s behavior and, more importantly, can increase the future likelihood of the behavior.  This process is called reinforcement.  Reinforcement is a consequence that influences behavior. It increases the likelihood that the behavior will occur again under those similar conditions Data paint a picture. Data give the what, when, where, and how regarding a behavioral event. The “what” is what most people focus on, such as what happened? Staff might interpret this as “he struck the CNA [certified nurse assistant].” But is that the whole picture? Does that really describe what happened?  To be more specific, it is best to know what happened right before the resident exhibited the behavior. Something in the environment set up the event that compelled the resident to strike the CNA. This is a key component in understanding resident behaviors. Whatever it may be, having data to interpret will help put interventions in place to reduce challenging behaviors.  How does one know if something is reinforcing the behavior it follows? One of the best ways is to look at the ABCs of an incident: Antecedent, Behavior, and Consequence.

An antecedent is the first link in this chain of events. It tells caregivers what happened right before the behavior of concern.  In the example above, the antecedent was the resident sitting alone in the bedroom. The behavior is what follows. The behavior was the resident screaming; following the behavior is its consequence. The consequence was staff rushing to the resident, providing a great deal of tactile stimulation, such as rubbing the resident’s arm or shoulder, coupled with verbal calming, such as “It’s okay; can I help you?” What happens after the behavior—the response to it—is what strengthens or weakens the behavior or increases or decreases the likelihood of that behavior reoccurring in the future.  It is the future response that should be controlled, based on the behavioral approach.  Documenting The ABCsWhile there are several methods for determining the antecedents and consequences of a behavior, the most basic, yet effective, tool is an ABC descriptive analysis sheet. It captures the time, location, antecedent, behavior, and immediate consequence.

This tool is simple but effective in gathering pertinent information to identify components that influence behavior. Behavior is a form of communication. Taking the example of a resident striking a staff member following assistance with an activity of daily living, one can determine that hitting is a form of expression of not wanting to participate in that activity. If the response or consequence to that behavior is to leave the resident alone, the behavior of hitting will increase, as the resident has learned that the striking behavior is successful in allowing them to escape from that particular demand. Proven SolutionsFollowing are some proven solutions for reducing this behavior: 1. Noncontingent Reinforcement. This has been proven to be an effective intervention with attention-seeking behaviors. This procedure involves providing reinforcement, such as attention from staff via verbal praise or high fives on a fixed schedule (every 15 minutes, every hour) or at random, completely independent of the behavior. In the example of the resident screaming, staff would provide social praise every hour, regardless if the resident is exhibiting screaming behavior or not.  2. Functional Communication Training. This strategy is useful to teach the resident functional communication skills to replace problem behavior.  Teaching the resident to either say, “Come talk to me,” or gesture, “Come,” with his hand when he would like a staff member’s attention, staff will provide the attention and verbally praise him for appropriately expressing himself. This social reinforcement will increase the likelihood of the resident verbalizing the phrase, “Come talk to me,” as opposed to yelling out for attention. Staff should continue to provide attention every time the resident appropriately asks for it. Repeat the procedure as necessary. 3. Behavior Momentum. This technique is helpful to assist with compliance. A staff member presents a series of easy-to-follow requests for which the resident has a history of compliance. When the resident complies with several high-probability requests in sequence, the staff member immediately gives the target request, such as taking medications, and uses the momentum of the high-probability response in assisting with compliance of the low-probability request of taking medication.  Following is an example of how this might work:Staff member: “Hey, give me a high five!” (a high-probability request).Resident: Slaps the staff member’s hand.Staff member: “Great job!” or “Throw the ball to me” (a high-probability request).Resident: Throws the ball to staff member.Staff member: “Awesome, let’s take your medications” (low-probability request).Resident: Takes medications.These are just a few interventions that have been proven to be successful when implemented to help shape behavior. However, with any event that nursing facility staff are faced with, collecting data will help formulate an effective treatment plan to reduce these challenging behaviors. Danielle Russo, MA, is neurorehabilitation program director at Kindred Rehabilitation and Nursing of Braintree in Braintree, Mass.
This is from Provider OnLine Magazine

Friday, October 28, 2011

Residents' Volunteerism Lifts Mood, Dampens Depression

Provider Long Term and Post-Acute Care October 2011

Nursing facilities have made tremendous strides in the past 25 years. An abundance of truly compassionate, highly trained caregivers is common in most facilities, and many facilities provide state-of-the-art services with deluxe accommodations.
Having highly competent staff working around the clock, being provided more choices in their daily lives, and having ample opportunities to socialize and engage in activities, it would seem that residents have everything they need, right? So why, according to the American Geriatrics Society, do nearly half of all nursing facility residents experience apathy and depression?
Historically, nursing facilities have borrowed the acute hospital model of care—clinical excellence and compassionate care. Both are needed and fundamental to what hospitals and nursing facilities do. This model works well in the acute-care setting where people are soon going back to their homes. However, for nursing facility residents, this model leaves them in the long-term position of a “care receiver.”

Even if the care is of the highest caliber and staff are beyond wonderful, residents are left with their greatest fear realized: “No one needs me anymore; I am now just a burden on society.”
Without an opportunity to give back in a real and meaningful way, the stage is set for apathy and depression.

Making The Switch

In 2008, staff members at Mission View Health Center in San Luis Obispo, Calif., were brainstorming about why their residents seemed unfulfilled and unhappy, in spite of excellent treatment and care—they didn’t have that spark in their eyes. Kathy, a resident, had recently asked the administrator, “Isn’t there something I can do? Any way I can help? I am bored to tears—and I mean tears.”
A nurse assistant commented that his “life would suck if all I had to look forward to every day was thanking everyone for helping me and no one needed me anymore.”
For the first time, it struck the group that the residents really were relegated to the role of “care receivers,” no matter how good the staff were as “caregivers.” As a result, Mission View adopted a service-based approach to health care, allowing residents to give as well as receive.
In order to accomplish this goal, Mission View would align itself with the needs of the local community. By partnering with a local homeless shelter, Mission View staff set the wheels in motion for their first resident service opportunity to feed the homeless in their community.
To support this venture, residents use the activities budget to make Helping Hands Homemade Soap and sell it at the local farmers market.
At first, residents weren’t particularly excited about what they considered another arts and crafts activity. However, when the residents understood the bigger picture of feeding the homeless, there was a change of heart. They realized they were needed and could make a real difference in their community.
Today, residents with dementia use water color to decorate the soap wrappers, three residents in their 90s hawk the soap at the farmers market, while residents with vision problems and physical disabilities help prepare the meals.
Six of the residents serve food onto the plates of 150 men, women, and children at the shelter every month.
Clearly, for the residents, the activity was not about making and selling soap, but about making a difference in their community. Because the shelter truly depends on them, the residents experience purpose and meaning in their lives, as well as the joy and fulfillment of service.

Giving More

Following the success of Helping Hands, Mission View began working with a local hospice agency. Within two weeks, the first seven-week resident training was underway, enabling residents to become certified hospice volunteers, helping other residents who sometimes simply needed someone to hold their hand.
Staff at Mission View started seeing that residents were regaining that spark in their eyes; after all, when they roll out of their room as a hospice volunteer to visit another resident, they are a hospice volunteer, not a resident, and have a hospice badge to prove it.
The service-based approach extends to facility activities as well. Even with physical and cognitive challenges, residents are more capable than commonly believed.
For example, a very unhappy and cranky resident who had suffered a stroke and left-sided paralysis changed his attitude when staff realized he was bilingual and called on him to become the facility Spanish instructor.
He now spends his week planning his class and making sure he is clean-shaven and looking sharp for his lesson. Residents love his class and can be seen practicing their Spanish up and down the halls.

Word Has Spread

Initially at Mission View, staff could not picture their residents feeding the homeless, opening a food bank distribution point at the facility, or running a nonprofit business like Helping Hands Handmade Soap. And yet, it is actually happening.
It’s easy to underestimate the potential of nursing facility residents, especially when they are in a depressed and apathetic state. It is important to focus on what they can do and remind them that they can still be valuable members of their community.
Today, 40 to 50 percent of all Mission View residents are actively involved in service projects. With Mission View’s success, additional nursing facilities under the Compass Health umbrella are adopting similar programs.
Residents in one facility are baking and selling dog biscuits to help rescue elderly dogs from a local shelter. Another group is selling handmade jewelry to buy backpacks and stock them with school supplies for local underprivileged children.
Having heard about the program, another provider with 30 facilities is adopting the same program for its residents.

The cost of this culture change? It’s virtually free, with a little time and effort.
Rev. Martin Luther King Jr. once said about service, “Everybody can be great, because anybody can serve … you only need a heart full of grace.”
To purchase the residents’ Helping Hands Handmade Soap, go to To view a documentary about Mission View's work, click here: 
Matthew Lysobey, MPH, LNHA, has worked in the long term care industry for more than 15 years and spearheads the Compass Health service-based approach in San Luis Obispo, Calif. Lysobey can be reached at

Thursday, October 27, 2011

Syracuse students take a lesson from the military on flag etiquette

Syracuse • Do you have to go to war if you’re really sick? Where do you go to the bathroom in battle? Is there really a 13 o’clock in the military?
Hill Air Force Base soldiers fielded those questions, and more, from wide-eyed fifth-graders at Bluff Ridge Elementary as they taught one of the most fundamental lessons of U.S. citizenship: How to care for the flag.
Although some of the questions were a bit off-topic — yes, there is a 1300 hours, or o’clock, in the military — the five servicemen answered them just the same as they taught students the basics of raising, lowering and folding the nation’s flag.
It was a lesson — taught as part of the school’s U.S. history curriculum — that hit a particularly pertinent crowd at the Syracuse school.
“It is the fifth graders’ role and responsibility to lower the flag after school,” said Stacey Clark, an office assistant and adviser to the student council. “It is something they take pride in. They can learn about the flag from a book, but it is so much more substantial when they learn it from men in military uniform.”
The soldiers first demonstrated how to fold the flag in triangle-fashion, then divided the students into groups to practice.
“If you know how to fold a paper football,” Staff Sgt. Hazam Peralta said, “you know how to fold an American flag. Just start from your left and don’t let it touch the ground.”
The lesson then continued with pointers about hats and voices and feet when raising and lowering the flag.
“The flag is raised quickly and lowered slowly,” Peralta said. “If you are wearing a hat, it needs to be removed. Stand with your feet together and your hand over your heart. No speaking while it is being raised or lowered. The whole point is to raise and lower the flag respectfully.”
Fifth-grade teacher Julie Wood said the Air Force tutorial had considerably more impact on the students than simply studying the information in a book.
“I’ve talked about the flag and we’ve read about it,” she said, “but they are so excited today. This has so much more meaning.”
Adam Winfrey, a student, characterized the presentation as “cool.”
“We learned what the stars and stripes mean,” he said. “There were originally 13 stars to represent the 13 colonies. Now there are more, but there are still 13 stripes.”
That excitement was shared by fellow classmate Alyssa Eggitt.
“I learned how to fold the flag and then when it is halfway down on the pole it means someone important died. I have more respect for the flag now.”
Among the presenters was Airman 1st Class Daniel Callahan, who has been in the service for nine months.
“It’s important for children to have pride in their flag and to instill values,” he said.
Because of Bluff Ridge Elementary’s proximity to Hill Air Force Base, Principal Traci Robbins said the military addition to the history curriculum is a good fit.
“We have so many local families that are connected to the military,” she said. “I thought it would be beneficial for the students to have that connection with the Air Force. There is no better way to teach respect.”
Flag facts
When folded properly, the U.S. flag is shaped like a triangle with only a blue field of stars showing.
The flags on a military uniform are in reverse, so it looks like the flag is flying behind the soldier.
Those in military uniform salute the flag rather than put their hands over their hearts.
The flag, when flown at half staff, should be hoisted to its peak first, then lowered into position.
The flag should never touch anything beneath it, such as the ground or the floor.

© 2011 The Salt Lake Tribune
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Wednesday, October 26, 2011

First our name in lights, now this!

CERTIFIED NURSING ASSISTANT SCHOOL NEAR COTTONWOOD HEIGHTS; CCcna opens new location at 75 E. Fort Union Blvd., Midvale, UT 84047

Picture of Claudia Wilcox and Linda Sheppard at CCcna's location at Garden Square, 75 East Fort Union Blvd. Midvale, UT 84047, dated: 10.26.2011, copyright Todd E. DeFeudis
CERTIFIED NURSING ASSISTANT SCHOOL NEAR COTTONWOOD HEIGHTS; CCcna opens new location at 75 E. Fort Union Blvd., Midvale, UT 84047
Claudia Wilcox and Carol Lindsay open their certified nursing assistant school, CCcna at a new location: Garden Square, 75 East Fort Union Blvd. Midvale, UT 84047, (801) 968-2262. The picture shows owner Claudia Wilcox and worker Linda Sheppard in their new office and classroom facility.
Their school has a certified nursing assistant program as well as phlebotomy basics (drawing blood from patients).
The school and accompanying certificates are great beginning education and certification that can help with many jobs in the medical field.
The school is nice and the staff is delightful. The certified nursing assistant class costs about $400. It is informatiive and well done.
For more information, view their website at
Great job CCcna! Thanks for traing people to care well and professionally in the community!

Tuesday, October 25, 2011

I told you NOT to eat POOH!

From WebMD Health News

Nasty Bugs Lurking on Your Cell Phone

Tim Locke

Nurse Rating: 4 stars  ( 13 Votes )            
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 October 14, 2011 — The next time you reach for your cell phone, consider this: A new study found that 92% of cell phones in the U.K. have bacteria on them - including E. coli -- because people aren't washing their hands after going to the bathroom.
The E. coli came from fecal bacteria, which can survive on hands and surfaces for hours.
Researchers from the London School of Hygiene & Tropical Medicine and Queen Mary, University of London looked at cell phones in 12 cities in the U.K.
They took 390 samples from cell phones and hands, which were then analyzed for germs. People were also asked about their hand hygiene.
Phone Filth and Other Facts
The study found:
  • 92% of phones had bacteria on them.
  • 82% of hands had bacteria on them.
  • 16% of hands and 16% of phones had E. coli bacteria, which is found in feces.
However, 95% of people said they washed their hands with soap where possible, which suggests we have a tendency to lie about our hygiene habits.
"We're pretty shocked to find the vast majority of mobile phones -- 92% -- had bacteria all over them. Often large numbers of bacteria,” said hygiene expert Val Curtis, PhD, of the London School of Hygiene & Tropical Medicine.
"That isn't necessarily something that we should worry about, but what is worrying is that 16% of mobile phones had E. coli on them. E. coli comes from human [and animal] feces,” she says. "That means that people with dirty hands are not washing their hands after using the toilet, for example. Then they're handling their mobile phones.”
It’s not just cell phones that the dirty hands are touching, Curtis says.
"They're also touching other surfaces as well,” she says. “They're spreading fecal bugs on everything they touch really."
Toilet Texting?
Is there a more worrying way the phones are getting contaminated -- by people using them while they're in the bathroom?
"We didn't ask people whether they'd used their phones in the toilet. That might be something that would be interesting to study," Curtis says. "People do tend to use their mobile phones everywhere they go. Perhaps we should discourage their use in the toilet."
So is having unclean hands a modern-day problem linked to our new technology?
"Humans have had infections since before they were human. It's a really ancient problem," she says. "Bugs are evolutionary masters at getting from person to person.”
Anything that you touch can become a source of infection, Curtis says. So hand washing after using the toilet is crucial.
Excuses, Excuses
Curtis says people can be quick to excuse their nasty habits.
"They say that they're in a hurry, they say that the water's too cold. People don't actually feel that their hands have got contaminated.
"Everyone knows they should do it, so it's not education that's the answer. We need to find other ways to remind people that it's disgusting that their hands are dirty and their hands get smelly and foul after the toilet,” she says. "Disgusting people with the state of their hands is probably the most effective way of getting people to wash their hands."
London School of Hygiene & Tropical Medicine and Queen Mary, University of London.
News release, Global Handwashing day.
Val Curtis, PhD, London School of Hygiene & Tropical Medicine.

Monday, October 24, 2011

CPR Guidelines

You probably know this if you've taken CPR lately but this CME article came out this month so I thought I would pass it on.
Also, Medscape is a GREAT place to get free CEU's if you need them!

This article is a CME/CE certified activity. To earn credit for this activity visit:

2010 AHA Guidelines: The ABCs of CPR Rearranged to "CAB" CME/CE

News Author: Emma Hitt, PhD
CME Author: Laurie Barclay, MD
CME/CE Released: 10/27/2010; Valid for credit through 10/27/2011
October 20, 2010 — Chest compressions should be the first step in addressing cardiac arrest. Therefore, the American Heart Association (AHA) now recommends that the A-B-Cs (Airway-Breathing-Compressions) of cardiopulmonary resuscitation (CPR) be changed to C-A-B (Compressions-Airway-Breathing).
The changes were documented in the 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, published in the November 2 supplemental issue of Circulation: Journal of the American Heart Association, and represent an update to previous guidelines issued in 2005.
"The 2010 AHA Guidelines for CPR and ECC [Emergency Cardiovascular Care] are based on the most current and comprehensive review of resuscitation literature ever published," note the authors in the executive summary. The new research includes information from "356 resuscitation experts from 29 countries who reviewed, analyzed, evaluated, debated, and discussed research and hypotheses through in-person meetings, teleconferences, and online sessions ('webinars') during the 36-month period before the 2010 Consensus Conference."
According to the AHA, chest compressions should be started immediately on anyone who is unresponsive and is not breathing normally. Oxygen will be present in the lungs and bloodstream within the first few minutes, so initiating chest compressions first will facilitate distribution of that oxygen into the brain and heart sooner. Previously, starting with "A" (airway) rather than "C" (compressions) caused significant delays of approximately 30 seconds.
"For more than 40 years, CPR training has emphasized the ABCs of CPR, which instructed people to open a victim's airway by tilting their head back, pinching the nose and breathing into the victim's mouth, and only then giving chest compressions," noted Michael R. Sayre, MD, coauthor and chairman of the AHA's Emergency Cardiovascular Care Committee, in an AHA written release. "This approach was causing significant delays in starting chest compressions, which are essential for keeping oxygen-rich blood circulating through the body," he added.
The new guidelines also recommend that during CPR, rescuers increase the speed of chest compressions to a rate of at least 100 times a minute. In addition, compressions should be made more deeply into the chest, to a depth of at least 2 inches in adults and children and 1.5 inches in infants.
Persons performing CPR should also avoid leaning on the chest so that it can return to its starting position, and compression should be continued as long as possible without the use of excessive ventilation.
9-1-1 centers are now directed to deliver instructions assertively so that chest compressions can be started when cardiac arrest is suspected.
The new guidelines also recommend more strongly that dispatchers instruct untrained lay rescuers to provide Hands-Only CPR (chest compression only) for adults who are unresponsive, with no breathing or no normal breathing.
Other Key Recommendations
Other key recommendations for healthcare professionals performing CPR include the following:
  • Effective teamwork techniques should be learned and practiced regularly.
  • Quantitative waveform capnography, used to measure carbon dioxide output, should be used to confirm intubation and monitor CPR quality.
  • Therapeutic hypothermia should be part of an overall interdisciplinary system of care after resuscitation from cardiac arrest.
  • Atropine is no longer recommended for routine use in managing and treating pulseless electrical activity or asystole.
Pediatric advanced life support guidelines emphasize organizing care around 2-minute periods of continuous CPR. The new guidelines also discuss resuscitation of infants and children with various congenital heart diseases and pulmonary hypertension.
The authors of the guidelines have disclosed no relevant financial relationships.
Circulation. 2010;122[suppl 3]:S640-S656.
Additional Resource
The 2010 AHA guidelines for CPR and emergency cardiovascular care are available on the AHA Web site.

Clinical Context

When the AHA established the first resuscitation guidelines in 1966, the original "A-B-Cs" of CPR were to open the victim's Airway by tilting the head back; pinching the nose and Breathing into the victim's mouth, and then giving chest Compressions. However, this sequence resulted in significant delays (approximately 30 seconds) in starting chest compressions needed to maintain circulation of oxygenated blood.
In its 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, the AHA has therefore rearranged the steps of CPR from "A-B-C" to "C-A-B" for adults and children, allowing all rescuers to begin chest compressions immediately. Since 2008, the AHA has recommended that untrained bystanders use Hands-Only CPR, or CPR without breaths, for an adult who suddenly collapses. The new guidelines also contain other recommendations, based primarily on evidence published since the previous AHA resuscitation guidelines were issued in 2005.

Study Highlights

  • The AHA has rearranged the A-B-Cs (Airway-Breathing-Compressions) of CPR to C-A-B (Compressions-Airway-Breathing).
  • Chest compressions are therefore the first step for lay and professional rescuers to revive an individual with sudden cardiac arrest.
  • This change in CPR sequence applies to adults, children, and infants, but excludes newborns.
  • "Look, Listen and Feel" has been removed from the basic life support algorithm.
  • Other changes in CPR recommendations for basic life support include the following:
    • Rate of chest compressions should be at least 100 times a minute.
    • Rescuers should push deeper on the chest, resulting in compressions of at least 2 inches in adults and children and 1.5 inches in infants.
    • Between each compression, rescuers should avoid leaning on the chest so that it can return to the starting position.
    • Rescuers should avoid stopping chest compressions and avoid excessive ventilation.
    • All 9-1-1 centers should assertively give telephone instructions to start chest compressions (Hands-Only CPR) when cardiac arrest is suspected in adults who are unresponsive, with no breathing or no normal breathing.
  • Dispatchers should provide instructions in conventional CPR for individuals who have presumably drowned or have had other likely asphyxial arrest.
  • For attempted defibrillation with an automated external defibrillator of children 1 to 8 years old, the rescuer should use a pediatric dose-attenuator system if one is available, or a standard automated external defibrillator if the pediatric dose-attenuator system is not available.
  • A manual defibrillator is preferred for infants younger than 1 year.
  • Key guidelines recommendations for healthcare professionals include the following:
    • Effective teamwork techniques should be learned and practiced regularly.
    • To confirm intubation and monitor CPR quality, professional rescuers should use quantitative waveform capnography to measure and monitor carbon dioxide output.
    • Therapeutic hypothermia should be incorporated into the overall interdisciplinary system of care after resuscitation from cardiac arrest.
    • For management and treatment of pulseless electrical activity (asystole), atropine is no longer recommended for routine use.
  • The new guidelines do not recommend routine use of cricoid pressure in cardiac arrest.
  • For the initial diagnosis and treatment of stable, undifferentiated regular, monomorphic wide-complex tachycardia, adenosine is recommended.
  • Pediatric advanced life support guidelines offer new strategies for resuscitating infants and children with certain congenital heart diseases and pulmonary hypertension.
  • The pediatric advanced life support guidelines emphasize organizing care around 2-minute periods of uninterrupted CPR.

Clinical Implications

  • In its latest guidelines, the AHA has rearranged the A-B-Cs of CPR to C-A-B. This change in CPR sequence applies to adults, children, and infants, but excludes newborns.
  • Key guidelines recommendations for healthcare professionals include focus on effective teamwork techniques, use of quantitative waveform capnography, and incorporation of therapeutic hypothermia into the overall interdisciplinary system of care. Atropine is no longer recommended for routine use for management of pulseless electrical activity (asystole).

Eat more chocolate

Chocolate Intake Benefits the Heart and Brain CME/CE
This article is a CME/CE certified activity. To earn credit for this activity visit:

News Author: Michael O'Riordan
CME Author: Penny Murata, MD
CME/CE Released: 09/06/2011; Valid for credit through 09/06/2012

Clinical Context

According to Ogbera in the January 12, 2010, issue of Diabetology & Metabolic Syndrome, approximately one fifth of adults worldwide are likely to have metabolic syndrome, a set of factors linked with a greater risk for type 2 diabetes and cardiovascular disease. The consumption of chocolate might be beneficial in the prevention of cardiometabolic disorders. A study by Allen and colleagues in the April 2008 issue of the Journal of Nutrition found that daily chocolate consumption had a positive effect on cardiovascular risk factors.
This meta-analysis by Buitrago-Lopez and colleagues assesses the association between chocolate intake and the risk for cardiometabolic disorders overall, in addition to the risk for cardiovascular disease, diabetes, stroke, and heart failure.

Study Synopsis and Perspective

In a city renowned for its love of food, it is only fitting that researchers presented the results of a new study in Paris, France, showing that chocolate is good for the heart and brain. In a presentation at the European Society of Cardiology (ESC) 2011 Congress, British investigators are reporting that individuals who ate the most chocolate had a 37% lower risk of cardiovascular disease and a 29% lower risk of stroke compared with individuals who ate the least amount of chocolate.
In the study, published online August 29, 2011 in BMJ to coincide with the ESC presentation, Dr Adriana Buitrago-Lopez (University of Cambridge, UK) and colleagues state: "Although overconsumption can have harmful effects, the existing studies generally agree on a potential beneficial association of chocolate consumption with a lower risk of cardiometabolic disorders. Our findings confirm this, and we found that higher levels of chocolate consumption might be associated with a one-third reduction in the risk of developing cardiovascular disease."
In this meta-analysis of six cohort studies and one cross-sectional study, overall chocolate consumption was reported, with investigators not differentiating between dark, milk, or white chocolate. Chocolate in any form was included, such as chocolate bars, chocolate drinks, and chocolate snacks, such as confectionary, biscuits, desserts, and nutritional supplements. Chocolate consumption was reported differently in the trials but ranged from never to more than once per day. Most patients included in the trials were white, although one study included Hispanic and African Americans and one study included Asian patients.
Of the seven studies, five trials reported a significant inverse association between chocolate intake and cardiometabolic disorders. For example, individual studies showed reductions in the risk of coronary heart disease (odds ratio 0.43; 95% CI 0.27–0.68), the risk of cardiovascular disease mortality (relative risk [RR] 0.50; 95% CI 0.32–0.78), and the risk of incident diabetes in men (hazard ratio 0.65; 95% CI 0.43–0.97).
Overall, the pooled meta-analysis results showed that high levels of chocolate consumption compared with the lowest levels of chocolate consumption reduced the risk of any cardiovascular disease 37% (RR 0.63; 0.44–0.90) and stroke 29% (RR 0.71; 0.52–0.98). There was no association between chocolate consumption and the risk of heart failure, and no association on the incidence of diabetes in women.
The researchers note that the findings corroborate the results of previous meta-analyses of experimental and observational studies in different populations showing a similar relationship between chocolate and cocoa consumption and cardiometabolic disorders.
"These favorable effects seem mainly mediated by the high content of polyphenols present in cocoa products and are probably accrued through the increasing bioavailability of nitric oxide, which subsequently might lead to improvements in endothelial function, reductions in platelet function, and additional beneficial effects on blood pressure, insulin resistance, and blood lipids," conclude Buitrago-Lopez and colleagues.
  1. Buitrago-Lopez A, Sanderson J, Johnson L, et al. Chocolate consumption and cardiometabolic disorders: systematic review and meta-analysis. BMJ 2011; DOI:10.1136/bmj.d4488. Available at:
Related Link
The Centers for Disease Control and Prevention's Division for Heart Disease and Stroke Prevention aggregates information from a range of sources and provides numerous downloadable materials helpful for patient education.

Study Highlights

  • The investigators identified 4576 articles from MEDLINE (from 1950), EMBASE (from 1980), the Cochrane Library (from 1960), Scopus (from 1996), Scielo (from 1997), Web of Knowledge (from 1970), AMED (from 1985), and CINHAL (from 1981) through October 5, 2010; reference lists; and contact with authors for other articles.
  • Inclusion criteria were randomized controlled trials, cohort, case-control, or cross-sectional studies; adult participants 18 years or older; study of the effects of levels of chocolate intake; outcomes related to cardiometabolic disorders; and no language restriction.
  • Cardiometabolic disorders included cardiovascular disease, myocardial infarction, stroke, ischemic heart disease, heart failure, diabetes, and metabolic syndrome.
  • Exclusion criteria were pregnant participants in studies and use of nonhuman subjects. Types of articles excluded were letters, abstracts, systematic reviews, meta-analysis, ecologic studies, and conference proceedings.
  • 7 studies with 114,009 participants were included in the analysis.
  • 6 were cohort studies, and 1 was cross-sectional.
  • 6 studies occurred in the community, and 1 occurred in the hospital inpatient setting.
  • The age range of participants was 25 to 93 years, and most participants were white.
  • In each study, the group with the highest chocolate intake was compared vs the group with the lowest chocolate intake.
  • Intake of chocolate bars, drinks, and snacks was assessed by food frequency questionnaires in 6 studies and by patient diaries plus dietary history in 1 study.
  • The reported outcomes included myocardial infarction, diabetes, cardiovascular disease, coronary heart disease, heart failure, and stroke.
  • No studies assessed metabolic syndrome as an outcome.
  • Follow-up ranged from 8 to 16 years for the cohort studies.
  • Analyses adjusted for age, sex, body mass index, physical activity, smoking, dietary factors, and education.
  • Higher chocolate intake was linked with a decreased risk for cardiometabolic disorders in 5 of 7 studies.
  • Higher chocolate intake was beneficial in the prevention of cardiometabolic disorders for 12 measures of association, but not for heart failure.
  • Subgroup analysis showed that higher chocolate intake was linked with a 37% reduction in any cardiovascular disease and a 29% reduction in stroke risk, but higher intake was not linked with a reduced risk for heart failure.
  • 1 study showed that higher chocolate intake was linked with a 31% reduced risk for diabetes.
  • There was no significant publication bias.
  • Limitations of the analysis include limited generalizability, heterogeneity in types and amounts of chocolate intake, and inaccuracy in reporting chocolate intake.

Clinical Implications

  • Higher chocolate intake is related to a decreased risk for cardiometabolic disorders overall in 5 of 7 studies.
  • Higher chocolate intake is related to a reduced risk for cardiovascular disease by 37%, diabetes by 31%, and stroke by 29%. There is no link between chocolate intake and heart failure.

Friday, October 21, 2011

Practice questions

1. A patient starts to choke while eating. What should be your first step?
a) Call the head nurse for assistance
b) Immediately perform abdominal thrust
c) Place the bed in an upright position and tap the patient’s back
d) Call 911
2. Your patient is going through his daily exercise routine then suddenly clutches at his chest and falls down, unconscious. Select the correct order of steps to follow.
a) Call for help, use an AED (automatic external defibrillator) if available, perform CPR until medical team arrives.
b) Perform CPR, use an AED, call for help
c) Call for help, perform CPR, use an AED until medical help arrives
d) Call the head nurse, you are not trained for CPR
3. While performing CPR, your patient regains consciousness. What should you do?
a) Place the patient in a recovery position.
b) Let them get up and resume their exercise.
c) Place them in a supine position until help arrives.
d) Tell them they had a heart attack.
4. Your patient has slipped and fallen down the stairs. You are certain that they may have a lower back or neck injury. What should you do?
a) Help the patient up and wait for other paramedics.
b) Call for help and 911 and try to stabilize the patient’s neck or back
c) Do not touch the patient, call 911. You may be aggravating an injury.
d) Place pillows and blankets under the patient’s head.
5. Elderly patients are most at risk when it comes to:
a) Poisons and chemical burns
b) Head injuries
c) Depression
d) Falls
6. Long term facilities like hospices often specialize in:
a) Home care
b) Diagnosis
c) Skilled labor care
d) Treatments
7. Your scope of practice is _________________.
a) The skills you are legally able to perform, without threat of liability.
b) Any skill you feel that you are competent enough to do.
c) Any skill that you have taken a class in.
d) Any skill that your place of employment requires you to perform.
8. Rigor Mortis is occurs when:
a) A fever goes beyond 40 degrees C (104 degrees F)
b) Calcium deposits go into the blood after death
c) Muscle spasms are too frequent
d) Joints have massive amounts of calcium in them
9. The first sign that a patient has suffered a stroke is often:
a) Loss of control or weakness of one side of the body, including slackening muscles on the face
b) Slurred speech and trouble understanding spoken language
c) Forgetfulness or confusion
d) Unconsciousness
10. Range of motion exercises for bed ridden patients help prevent:
a) Embolisms
b) Atrophy
c) Lactic build up
d) Low blood pressure

1. B
2. A
3. A
4. B
5. D
6. A
7. A
8. B
9. A
10. B

72 years together: The couple who died holding hands

   72 years together: The couple who died holding handsAfter 72 years of marriage, Norma and Gordon Yeager died within one hour of each other — and were buried in a single coffin

Norma and Gordon Yeager had each promised to live as long as the other.   Photo: YouTube
Here's a love story for the ages — or the movies. Iowa couple Norma and Gordon Yeager were both in their 90s and had been married 72 years when they were hospitalized following a car accident. The nurses and doctor kept the two together in the intensive care unit, and they lay there, barely responsive but holding hands. Gordon passed away, and, exactly one hour later, Norma followed him, still holding his hand. "They just loved being together," says their son Dennis. "He always said, 'I can't go until she does because I gotta stay here for her.' And she would say the same thing." Here, a brief guide to their incredible story:

Who was this extraordinary couple?
Ninety-year-old Norma and 94-year-old Gordon Yeager met while Norma was still in high school and Gordon was working at the Chevrolet Garage in State Center, Iowa. They were married on May 26, 1939, the day Norma graduated. They had four children together, one daughter and three sons. Tragically, their two middle children were killed in car accidents. "They believed in marriage," says their son, Dennis. "They chose each other and once they had committed, that was it."

How did they die?
Last Wednesday, as the couple was driving into town, Gordon mistakenly pulled out in front of another car. The Yeagers were rushed to the hospital following the collision and given a shared room in intensive care. Though they were "not really responsive," they held hands as they lay there, side-by-side. At 3:38 p.m, Gordon passed away, but, then, his family noticed his heart monitor was still beeping. "It was really strange," Dennis says. Then a nurse looked and saw that the couple's hands were still clasped. "Her heart was beating through him and [the monitor was] picking it up," Dennis says. At 4:48 p.m., one hour after her husband, Norma passed away as well. "Neither one of them would've wanted to be without each other," says their daughter, Donna Sheets. "We were very blessed, honestly, that they went this way."

How will they be buried?
At their funeral on Tuesday, Norma and Gordon shared a casket and held hands. Once cremated, their ashes will be mixed together. They are survived by their two children, Norma's sister, Virginia Keil, Gordon's brother, Roger, 14 grandchildren, 29 great-grandchildren, and one great-great grandchild. "We don't hear love stories like Norma and Gordon's anymore," says Lindsay Mannering at The Stir. "We hear about lying, cheating, and divorce. Hopefully there are couples all over the world who share a similar story because I'd like to live in a world where this is the norm and not the exception."

Interesting ethical debate

                    Pat Robertson Says Alzheimer's Makes Divorce OK
Sept. 15, 2011—
Religious broadcaster Pat Robertson stunned "700 Club" viewers Tuesday when he said divorcing a spouse with Alzheimer's disease was justified.
Robertson, chairman of the Christian Broadcasting Network and former Republican presidential candidate, said he wouldn't "put a guilt trip" on someone for divorcing a spouse with Alzheimer's disease, calling Alzheimer's itself "a kind of death."
The remarks sparked outrage throughout religious and medical communities.
"I'm just flabbergasted," said Joel Hunter, senior pastor of the 15,000 member Northland Church in Orlando, Fla. "I just don't know how anyone who is reading Scripture or is even familiar with the traditional wedding vows can come out with a statement like that. Obviously, we can all rationalize the legitimacy for our own comfort that would somehow make it OK to divorce our spouse if circumstances become very different or inconvenient. ... That's almost universal, but there's just no way you can get out of what Jesus says about marriage."
Hunter, who is also a presidential appointee to an advisory council on faith-based and neighborhood partnerships, said Robertson's words could lead people to interpret typical marital woes as proof that the spouse they married is symbolically dead, and they are therefore free to move on.
"Obviously, you could do this for anything. ... My husband watches and plays video games, and so he has left the marriage and it's kind of like a death," he said. "It's not death, and so we can't start describing things as death that are really not death, and we have to stop trying to mischaracterize what Scripture says for our own convenience."
Leith Anderson, president of the National Association of Evangelicals, said marriage is a lifelong commitment between a man and a woman that calls for faithfulness in the best of times and the worst of times. Quoting Corinthians, Anderson said, "The wife's body does not belong to her alone but also to her husband. In the same way, the husband's body does not belong to him alone but also to his wife. You can't quit your own body with Alzheimer's, so you shouldn't quit your husband's or wife's body either."
Doctors and social workers who work with families affected by Alzheimer's disease were similarly dismissive of Robertson's advice.
"To condone abandoning one's spouse in the throes of this mind-robbing illness is absurd," said Dr. Amanda Smith, medical director at the University of South Florida Health Alzheimer's Center in Tampa. "While Alzheimer's certainly affects the dynamic of relationships, marriage vows are taken in sickness and in health."
An estimated 5.4 million Americans have Alzheimer's disease – a figure expected to rise sharply as baby boomers enter their older years. And about 80 percent of Alzheimer patients who live at home are cared for by family members.
Robertson's comments came after a viewer asked what advice he should give a friend who had been seeing another woman since his wife had been diagnosed with Alzheimer's.
"I know it sounds cruel, but if he's going to do something, he should divorce her and start all over again, but make sure she has custodial care and somebody looking after her," Robertson said.
But the Rev. A.D. Baxter, a social worker with Cole Neuroscience Center at the University of Tennessee Medical Center, said care from a loved one is irreplaceable.
"When being cared for by a spouse, the love of that spouse is often what enables a person with Alzheimer's disease to continue on and not feel abandoned," said Baxter, adding that caregivers need support, too. "Many believe a true friend does not abandon in the time of need."
The progressive symptoms of Alzheimer's can put stress on relationships, leaving caregivers to cope with the loss of intimacy and other aspects of adult romantic relationships, said Dr. Jason Karlawish, a professor of medicine and medical ethics and assistant director of the Penn Memory Center in Philadelphia.
"There's no question that this is an issue," said Karlawish. "But to a spouse who's struggling with this kind of issue, I would want to say after the patient has left this world, you want be able to look back and say you treated that person with dignity."
Zaven Khachaturian, president of the Maryland-based Campaign to Prevent Alzheimer's Disease by 2020, said that Robertson's logic could have parents abandoning newborn babies.
"After all, a newborn presents to the caregiver exactly the same set of caregiver burden," said Khachaturian. "Both the infant and the person with Alzheimer's must be fed, cleansed, they are highly emotional, sleep a lot, they have wrinkled skins. If neglected, they will die. Does this mean caregivers must abandon newborn infants because it is not convenient to take care of them?"
New technologies are making it possible to diagnose Alzheimer's disease earlier, while patients have the ability to understand the road ahead of them.
"I think this highlights the need for couples and families to have discussions early in any illness, and preferably before illness strikes so that person's decisions and preferences are known and respected," said David Loewenstein, a clinical neuropsychologist at University of Miami's Miller School of Medicine.
Robertson's advice was for a male caregiver. But sometimes it's the patient who wants to start a new relationship.
"I have seen both caregivers and patients enter into new relationships during the course of dementia. How they choose to handle it is up to them. All parties dealing with this disease suffer to some extent and deserve to find happiness," said USF's Smith. "Ultimately, the decision for any couple to divorce, for any reason, is a private and difficult one."
Some couples stay married but form new relationships, too.
"There are many spouses who are devoted to the affected person with Alzheimer's, and yet form new relationships as they also care for their spouse," said Sandra Weintraub, professor of neurology and a neuropsychologist at the Cognitive Neurology and Alzheimer's Disease Center at Northwestern University Feinberg School of Medicine. "It's hard to negotiate living with Alzheimer's disease but dictating what's good and bad is not useful.
"Every person needs to make their own decisions and to consider all parties involved. I sincerely hope the good reverend never has to have Alzheimer's to experience his advice first hand."
Tim King, spokesman for the Christian organization Sojourners, said Robertson's controversial statement was encouraging in at least one regard.
"I'm actually encouraged to hear someone like Pat Robertson say we're not really in a position to judge another person," King said. "I can't imagine the difficulty that a spouse would have to see someone go through that type of change and transformation. ... I don't know anyone who is in the position to judge another type of person who is having to make those type of decisions. It should never be taking lightly; it should never be an easy decision. Dealing with marriage is serious and making a big decision like that should be hard."
A representative for Robertson's network told the Associated Press that there would be no further comment on the matter.

Tuesday, October 18, 2011

Wheelchair takes Clearfield High basketball player around the globe

Wheelchair takes Clearfield High basketball player around the globe
Leah Hogsten | The Salt Lake Tribune Spencer Heslop, 17, works out with fellow members of the Wheelin' Jazz basketball team at the Sorenson Multicultural Center. Heslop is a Clearfield High senior who just returned from the Netherlands, where he participated in a Paralympic camp.
Spencer Heslop took his love of basketball — and a wheelchair — halfway around the globe to represent the United States in a Paralympics Youth Camp.
The Clearfield High senior was one of seven Americans picked to participate in a weeklong camp in The Netherlands, thanks to his accomplishments on and off the basketball court.
Spencer doesn’t take life at a jog. He’s an Eagle Scout, a member of the National Honor Society and an alto saxophone player in his school’s symphony band. He has a 4.0 GPA and is enrolled in three Advanced Placement classes.
All of those things — plus his athleticism —helped land him a spot in a basketball camp nearly 5,000 miles away. He was selected based on a written essay, his sports background and academic achievements.
“There are those who don’t like the word disability because it takes away the ability,” Spencer’s father, Daron Heslop, said. But “his disability has given him a lot of opportunities that other kids haven’t had. He could have chosen to do nothing. Instead, he’s chosen to do many things. He finds a way to do whatever he wants.”
Spencer was born with lipomeningocele, a form of spina bifida.
“We didn’t know until a week after he was born that he had spina bifida,” his mother, Kerry Heslop, said. “He had his first surgery at 5 1/2 weeks old. He has had three more back surgeries and several on his legs since then.”
Consequently, Spencer uses forearm crutches to walk. The wheelchair comes in handy for sports, long strolls and day-to-day commuting between school classes.
Spencer’s mother describes her son “as always athletic.”
“He plays wheelchair tennis,” she said, “but basketball is his first love.”
He plays for the Junior Wheelin’ Jazz, a team of Utah wheelchair athletes from towns as far-flung as Springville, Stansbury Park and Henefer. He was recruited from a Clearfield city ball club. Playing on a state team has given him the chance to play in tournaments around the nation. His team practices twice a week and will participate in a national tournament in November.
Junior Wheelin’ Jazz Coach Marilyn Blakley describes Spencer — a soft-spoken athlete, by nature — as “our silent weapon.” He has a knack for knowing when to pass the ball and when to make his move, she said. And he’s always a team player.
Blakley said Spencer’s experience overseas will benefit the team.
“The team can see that dreams really do come true,” she said. “The goals you set are real.”
Spencer characterized his Paralympics play, simply, as “a neat experience.”
“It was hard at first because we didn’t speak the same language,” he said, “so we had to work hard to communicate. I discovered that sports can bring so many cultures together and unite them in one goal.”
His mother is proud.
“I am most proud of his positive attitude,” she said. “He doesn’t let anything slow him down. If there is something he wants to do, he finds a way to do it. He has never looked at his condition as a negative. His positive attitude builds his character and determination, which allows him to accomplish what he wants.”
So what’s in Spencer’s future? College. He has his eye on the University of Illinois, which has a respected wheelchair basketball team. He also plans to serve a mission for The Church of Jesus Christ of Latter-day Saints and participate in the Paralympics.
“It is important to try new things,” he said. “If you think you can’t do something because of a disability, or you feel something is holding you back but you try anyway, it can really be a blessing. Get out of your comfort zone and try something new.”
Did you know:
Spina bifida occurs in 7 of every 10,000 live births in the United States. The Spina Bifida Association estimates that more than 166,000 people in the U.S. suffer this birth defect.

© 2011 The Salt Lake Tribune

Report: Theft of Utah seniors’ assets could reach $365M annually

Report: Theft of Utah seniors’ assets could reach $365M annually
A draft report estimates Utah’s elders may have suffered losses of nearly $1 million per day last year because of financial abuse, a state legal enforcement officer said Wednesday.
Jilenne Gunther, an official with Utah Adult Protective Services, said a study of 80 reported cases of financial abuse of Utahns age 65 and older in 2010 leads her to believe the average victim is exploited to the tune of $96,300. The numbers are preliminary for a final report to be released later this year, but Gunther said costs from unreported cases could reach $365 million annually.
A similar report issued in February, based on 2009 data, showed the theft of seniors’ assets cost individuals, taxpayers, businesses and the state government $52 million annually, a figure Gunther said was conservative. She said the crimes have grown worse as a result of the recession. And, once again, the most common perpetrators are elders’ children and grandchildren.
“The enemies are often close to them. And that’s disturbing,” she said. “One of the things I’ve noticed is a lot of times these seniors are being exploited because they need help with their finances.”
Utah was the first state to take on a large study of elder financial abuse. The Utah Bar Association has offered assistance to other states and the American Bar Association to develop grant funding for similar programs.
Gunther has found that one of the main sources of exploitation comes when an adult child or grandchild has been given financial power of attorney for an elder relative, which allows them access to the relative’s bank accounts.
A typical case, she said, would be a woman with limited capacity who asks her adult child for help with finances.
“No one watches or oversees that child, which leaves that senior open to exploitation even more so due to her limited capacity,” Gunther said. “They then go on shopping sprees, buy cars, buy their pornography, all with their loved ones’ money.”
In about half of elder financial abuse cases, she said, “if there had been a trusted monitor, the abuse could have been stopped sooner or avoided altogether.”
The Bank of American Fork has held a series of seminars where Gunther spoke on elder financial abuse. The bank also collaborated with Gunther to set up a monitoring program it calls AccountSmartTools for Seniors, a package of products designed to prevent fraud for customers age 55 and older.
The program, launched Wednesday and expected to require a small fee, offers third-party online monitoring and other services in which trusted monitors keep watch over bank transactions.
Salt Lake City resident Marti Weber attended a September seminar where Gunther spoke about the problem. Weber’s mother recently had been a victim of traveling fraudsters who “repaved” the driveway to the mother’s home in rural Colorado with a water-soluble slurry. By the time Weber’s brother figured out the scam, the check her mother had written was already cashed.
Though the scammers didn’t otherwise invade the mother’s account, Weber felt duly warned. Weber said she hopes Colorado banks soon offer the same sort of watchdog services the Bank of American Fork has implemented.
“I see this as a really smart way to handle money,” she said. “We weren’t very proactive in my family about this. If there’s one message I’d like to see get out, it’s ‘don’t think this won’t happen to you.’”
Help to fight elder financial abuse
The Bank of American Fork has introduced a package of protections designed to avoid financial abuse of its older customers, working with Jilenne Gunther, Utah Adult Protective Services legal enforcement officer. For information on the bank program:

Thursday, October 6, 2011

Predictors of Registered Nurses' Willingness to Remain in Nursing

 Jane Marie Kirschling, DNS, RN, FAAN; Charles Colgan, PhD; Bruce Andrews, PhD

Posted: 09/22/2011; Nurs Econ. 2011;29(3):111-117. © 2011 Jannetti Publications, Inc.

Abstract and Introduction


The evolving nursing shortage in the United States and globally is a subject of considerable attention from researchers, the health care industry, higher education, and policy makers, both at the federal and state levels. Unlike past shortages, this one involves both the demand and supply parts of the equation. Consequently, multiple strategies must be put into place to offset the projected shortage of over 260,000 registered nurses (RNs) in 2025 (Buerhaus, Auerbach, & Staiger, 2009).
Retaining members of the current nursing workforce and increasing the number of new graduates are major strategies being addressed across the health care industry and higher education. In relation to retention, one of the short-term strategies that 34% of the 32 hospitals in the Community Tracking Studies are using is flexible scheduling, which includes a "broader range of shift types and self-scheduling" (May, Bazzoli, & Gerland, 2006, p. w319). Although the national trend is toward 12-hour shifts in acute care, there is evidence that older nurses prefer 8-hour shifts (Hoffman & Scott, 2003; Mion, Hazel, Cap, Fusilero, Podmore, & Szweda, 2006). However, Shullanberger (2000), in an integrative review of the literature, found that 12-hour shifts, in contrast to 8-hour shifts, were less fatiguing.
According to Norman and colleagues (2005), based on their national survey of 1,783 nurses:
Beyond focusing on retaining older RNs, it is important that employers initiate strategies to retain RNs who are approaching their 40s. Data in this survey showed that, as RNs enter their 4th decade, there is a strong tendency to shift employment into non-acute care settings. Strategies should be developed and tested that encourage retention in direct patient-care positions in acute care environments (p. 289).
Using a national sample to explore the impact of flexible scheduling on RNs who "intend to leave their current positions in the next 3 years," Ulrich, Buerhaus, Donelan, Norman, and Dittus (2005) found "more flexible scheduling would be very likely (29%) or somewhat likely (24%) to cause them to reconsider leaving" (p. 393).
In this study, responses from 8,038 nurses in Maine are used to elaborate on these previous studies by examining in some detail the relationship between scheduling and propensity to stay or leave the nursing profession as this relationship is mediated by a number of factors. Maine has been fortunate to date in maintaining its RN workforce, but this is not expected to continue. In 2000, there were 1,023 RNs per 100,000 population (national average 780) and the projected vacancy rate was 12% and was expected to grow to 31% in 2020, according to federal forecasts (U.S. Department of Health and Human Services Health Resources and Services Administration Bureau of Health Profes sions, 2001, 2000). Maine's Department of Labor projects the following employment growth in the health care sector between 2002-2012: ambulatory health-care services 32% (net 7,542), nursing and residential care facilities 29% (net 6,427), and hospitals 21% (net 5,405) (Maine Department of Labor, 2004). In addition, they project 3,469 additional jobs for RNs, which reflects 27% growth, and that annually there will be 1,097 openings (Maine Department of Labor, 2005).
Maine's 13 nursing programs produced 610 graduates in 2004-2005, up from a low of 392 in 2001-2002 (Kirschling, 2006a). It is important to note that the Maine State Board of Nursing has historically licensed to another jurisdiction the same number of out-of-state nurses that it licenses to the State of Maine. What this means for Maine is that retention of the existing workforce is an essential part of the solution, as well as increasing capacity in Maine's nursing programs.
A major question, therefore, about the adequacy of the future supply of nurses is how many will stay in the profession. Of course, this is partly a question about considerations common to any job such as when will people retire. For the baby-boom generation (those born between 1946 and 1964), which composed 65% of the nursing profession at the time of the survey reported here, this is a particularly critical question, since 84% of the nursing profession (at the time of the survey) was either in the baby-boom generation or older.
There are other aspects peculiar to the nursing profession that increase the urgency of identifying the factors affecting the decision to remain in the profession as part of the response to nursing shortages. These include the high-stress nature of many nursing duties and the ability to respond to the rapidly changing technological and organizational context of the nursing profession.

The Data Set

The survey reported here was conducted in cooperation with the Maine State Board of Nursing, which agreed to include a two-page survey with all license-renewal applications beginning September 1, 2002 and concluding August 31, 2004 for all nurses in the 2-year license renewal cycle. The resulting data are referred to as the Maine Minimum Data Set. Completing the survey was voluntary and its return served as informed consent. Returned surveys were separated from the renewal application for data entry and participants did not include their name or license number on the completed surveys.
The Maine Minimum Data Set was developed by the first author, working with key stakeholders. Agreement was reached on 19 items focused on education, advanced practice, work status, future plans, average work hours, employment setting, employer and residential ZIP codes, position, year born, race/ethnicity, gender, and, if not one, the reason for not being employed as a LPN or RN. A number of the items were drawn from the Colleagues in Caring minimum supply-side data elements (Lacey, Hoover, McKay, O'Grady, & Sechrist, 2005). A total of 15,960 nurses returned usable surveys, of which 1,995 were licensed practical nurses (LPNs) and 13,714 were RNs (Kirschling, 2006b). For this analysis, we focused on the respondents who were RNs and who were currently working in nursing.
For average work hours, respondents were asked to respond to the following four information requests that relate to their primary nursing position:
  1. Write in the average number of hours you were hired for in a typical week.
  2. If you are actively seeking to change the number of hours you are hired for, write in the number of hours you would prefer to work in a typical week.
  3. Write in the average number of actual hours worked in a typical week.
  4. Write in the average number of hours per week spent providing direct care (if you don't provide direct care, enter 00).
For future plans, the respondents were asked, "Do you plan to be working in nursing 5 years from now?", and the response options were "Yes", "No", and "Uncertain." Those who answered "Yes" or "No" to the future plans in 5 years question totaled 8,038, and their responses composed the data set analyzed. "Uncertain" respondents for this question were not included in the data set.
Table 1 provides descriptive information on the 8,038 RN respondents as well as two subsamples: those who were actively seeking to change the number of hours worked (n=1,831) and those not actively seeking to change the number of hours worked (n=6,207).

Table 1. Descriptive Information: Combined Sample, RNs Actively Seeking to Change Number of Hours Worked, and RNs Not Actively Seeking to Change Number of Hours Worked

Combined Sample (8038)Actively Seeking to Change number of hours Worked (1831).Not Actively Seeking to change Number of Hours Worked (6,207)
Average Age (in years) 46.245.946.3
Age Categories
% 21–30 years7.17.57.0
% 31–40 years21.220.821.3
% 41–50 years35.937.635.4
% 51–60 years30.028.830.3
% 61+ years5.95.26.1
% Female92.791.893.0
% Male7.38.27.0
Highest Education Nursing
% Diploma22.521.023.0
% Associate degree33.135.732.3
% Baccalaureate degree34.833.235.3
% Master's degree9.09.78.8
% Doctoral degree any field0.60.40.7
Nursing Employment Setting
% Hospital57.859.157.4
% Ambulatory care8.68.98.5
% Public/Community health3.02.53.1
% Occupational health1.21.21.2
% Insurance company1.92.01.8
% Long-term care9.09.18.9
% Home health care5.55.75.4
% Nursing education1.40.91.6
% School health3.42.63.7
% Other8.48.08.4
Role with Primary Employer
% Staff/Direct care nurse60.259.960.5
% Quality assurance/Infection control1.00.71.0
% Discharge planner2.32.12.4
% Utilization review/Outcome management/Other insurance related role2.22.42.1
% Staff development1.21.41.1
% Facility/Nursing department administrator or supervisor6.96.67.0
% Team leader/Charge nurse, nurse manager, head nurse11.112.010.7
% Educator (college/university)
% Researcher/Consultant1.11.11.0
% Nurse practitioner, certified nurse midwife, clinical nurse specialist, nurse anesthetists8.69.68.3
% Other4.54.54.5
Plan to Be Working in Nursing in 5 Years
% Yes93.492.993.5
% No6.67.16.5
Average Hours for Typical Week
Worked minus hired = contract gap3.14.32.8
Preferred (if seeking to change hours)n/a31.1n/a
Worked minus preferred = schedule gapn/a6.7n/a
Spent providing direct care24.625.124.4
Spent providing non-direct care = direct care gap12.612.712.6


We hypothesize that, if scheduling and number of hours worked are factors in whether someone is willing to stay in nursing, dissatisfaction with number of hours worked is a precursor to leaving the profession. In the case of a survey of this type, that precursor effect should be manifest by an association with the stated preference for remaining in nursing.
Respondents were asked, "If you are actively seeking to change the number of hours you are hired for, write in the number of hours you would prefer to work in a typical week." Answers to this question yield both a dichotomous variable indicating whether a change in hours is being sought and a variable expressing the level of preference. The dichotomous variable "Actively Seeking to Change Hours" can then be analyzed and used to break the data set into two groups based on whether they are (or are not) seeking to change their number of hours worked. These two subsets can then be analyzed for their relationship to their expectations about staying in the nursing profession. (The data analysis excluded LPNs and those for whom responses to any of the relevant variables were missing.)
Analysis of the relationships with nine potential explanatory variables was conducted using multivariate logistic regression. The examined explanatory variables were categorized into two groups. The first comprised six demographic characteristics of the respondent, and the second comprised three gaps defined in terms of numbers of hours worked. The first group consisted of:
  1. Age (expressed as an integer).
  2. Years in nursing profession (expressed as an integer).
  3. Gender
  4. Education (defined as highest degree/diploma held).
  5. Employer type, including:
    • Hospital
    • Ambulatory care
    • Home health care
    • Insurance company
    • Long-term care
    • Public/Community health
    • School health
  6. Primary nursing function as reported on the survey:
    • Discharge planner, case manager
    • Facility/Departmental administrator or supervisor
    • Nurse practitioner, nurse mid wife, clinical nurse specialist, nurse anesthetist
    • Quality assurance, infection control nurse
    • Researcher, consultant
    • Staff development nurse
    • Team leader/Charge nurse, nurse manager, head nurse
    • Utilization review, outcomes management, other insurance-related nursing roles
    • Other
The second group of explanatory variables consisted of the reported "contract gap," the "schedule gap", and the "direct-care gap". We define the "contract gap" as the difference between the respondent's actual number of hours worked and the number of hours for which they were hired (actual worked minus hired). The "schedule gap" is the difference between the actual number of hours worked at the time of the survey and the preferred number of hours worked (actual worked minus preferred). We also tested the hypothesis that the number of hours not spent directly caring for patients is negatively associated with a desire to stay in nursing by examining the "direct-care gap" (total hours minus direct care hours).


As depicted in Table 1, the contact gap for those actively seeking to change the number of hours worked was 4.3 hours, 1.5 hours greater than for those not actively seeking to change the number of hours worked. The schedule gap for those actively seeking to change the number of hours worked was 6.7 hours. The direct care gap was similar between the two groups with those actively seeking to change spending 12.7 hours in non-direct care and those not actively seeking to change spending 12.6 hours in non-direct care.

Table 1. Descriptive Information: Combined Sample, RNs Actively Seeking to Change Number of Hours Worked, and RNs Not Actively Seeking to Change Number of Hours Worked

Combined Sample (8038)Actively Seeking to Change number of hours Worked (1831).Not Actively Seeking to change Number of Hours Worked (6,207)
Average Age (in years) 46.245.946.3
Age Categories
% 21–30 years7.17.57.0
% 31–40 years21.220.821.3
% 41–50 years35.937.635.4
% 51–60 years30.028.830.3
% 61+ years5.95.26.1
% Female92.791.893.0
% Male7.38.27.0
Highest Education Nursing
% Diploma22.521.023.0
% Associate degree33.135.732.3
% Baccalaureate degree34.833.235.3
% Master's degree9.09.78.8
% Doctoral degree any field0.60.40.7
Nursing Employment Setting
% Hospital57.859.157.4
% Ambulatory care8.68.98.5
% Public/Community health3.02.53.1
% Occupational health1.21.21.2
% Insurance company1.92.01.8
% Long-term care9.09.18.9
% Home health care5.55.75.4
% Nursing education1.40.91.6
% School health3.42.63.7
% Other8.48.08.4
Role with Primary Employer
% Staff/Direct care nurse60.259.960.5
% Quality assurance/Infection control1.00.71.0
% Discharge planner2.32.12.4
% Utilization review/Outcome management/Other insurance related role2.22.42.1
% Staff development1.21.41.1
% Facility/Nursing department administrator or supervisor6.96.67.0
% Team leader/Charge nurse, nurse manager, head nurse11.112.010.7
% Educator (college/university)
% Researcher/Consultant1.11.11.0
% Nurse practitioner, certified nurse midwife, clinical nurse specialist, nurse anesthetists8.69.68.3
% Other4.54.54.5
Plan to Be Working in Nursing in 5 Years
% Yes93.492.993.5
% No6.67.16.5
Average Hours for Typical Week
Worked minus hired = contract gap3.14.32.8
Preferred (if seeking to change hours)n/a31.1n/a
Worked minus preferred = schedule gapn/a6.7n/a
Spent providing direct care24.625.124.4
Spent providing non-direct care = direct care gap12.612.712.6
The relationships between age, seeking/not seeking to change hours, and expressed likelihood of staying in nursing within 5 years are shown in Table 2. The overall statistical level of significance of the independent variable is given by the p value of the logistic regression coefficient in each model.

Table 2. The Age Effect

AgeSeeking to change hours p = <0.0001Not seeking to Change hours p = <0.0001
1.14 times less likely to stay1.16 times less likely to stay
As expected, age is significantly directly related to an expressed reduction in likelihood of staying in the nursing profession for both those seeking and not seeking schedule changes. The influence of age is very similar (statistically the same with a p value = 0.177) for both groups in that older respondents are less likely to stay in nursing (in the next 5 years) than younger respondents. As expected, the strong direct relationship between age and years in profession caused the nursing career duration to become insignificant for both groups.
Table 3 shows the results of the analysis of educational levels and expectations about staying in nursing. In interpreting the results of the two logistic regression models (one for those "seeking to change hours" and one for those "not seeking to change hours"), each value of the independent variable under examination is compared to one reference value chosen by the authors. This "reference group" is shown in the upper left corner of each table. For the RN diploma group, there is a significant relationship between the highest nursing degree and the propensity to leave nursing within the group not seeking to change their hours. Among those seeking to change their hours, there is also a significant relationship among those with RN diplomas and associate degrees and master/doctorate degrees, and the relationship is in the hypothesized direction. That is, as educational levels increase, there is an increased likelihood they will stay in nursing. How ever, this educational effect is much stronger among those seeking to change their hours.

Table 3. The Education Effect

Highest Nursing Degree ref: Master's or DoctorateSeeking to change hours p = 0.0121Not Seeking to change hours p = 0.0007
RN diploma3.32 times less likely to stay1.95 times less likely to stay
Associate2.83 times more likely to stayNs
ns = not significant (p = 0.05)
The influence of the employment setting was examined by testing the relationship with the type of employer and the type of nursing work performed. No statistically significant relationship was found between the stated plans about staying in nursing and either the type of employer or nursing function. This was true for both those actively seeking to change their work hours and those who were not seeking such a change. Further, for both those seeking and not seeking schedule changes, gender was not a significant factor nor was the volume of non-direct care work (the "direct-care gap").
This analysis suggests that, other than age and educational level, which do have predictable relationships with likelihood of staying in nursing, there is relatively little about the demographic characteristics measured in the survey that is associated with a likelihood of leaving nursing. However, the work schedule circumstances show much stronger relationships.The first element of scheduling to be examined is the "contract gap," the difference between the hours actually being worked and the hours for which one was hired (actual worked minus hired). The second gap examined is the "schedule gap," which is the difference between one's actual worked hours and preferred hours (actual worked minus preferred).
The impacts of each additional hour worked in excess of that for which the respondent was hired are presented in Table 4. For both those seeking and those not seeking changes in hours, work schedules whose magnitudes fell short of the hours promised at hiring did not significantly influence their propensity to leave or stay. However, for both groups, providing more hours than promised at the time of hiring had a favorable effect on an individual's propensity to stay, particularly with those seeking schedule changes. How ever, among those not interested in changing their schedule, more than 10 additional hours above the level they were promised at hiring is not attractive.

Table 4. The Contract Gap Effect (Hours Worked-Hours Hired)

Hours worked – Hours Hired ref: 0Seeking to change hours p = <0.0001Not Seeking to change hours p = 0.0044
≤ -1nsns
[1, 5]2.29 times more likely to stay1.37 times more likely to stay
[6, 10]2.83 times more likely to stay1.71 times more likely to stay
≥ 113.05 times more likely to stayns
ns = not significant (p = 0.05)
The "schedule gap" is examined in Table 5. This is the gap between the hours a respondent actually works and preferred level of hours (if seeking to change hours). As the gap between the number of hours actually worked and the number of hours preferred working increases above 10, the likelihood of staying in nursing decreases, with the odds of staying declining even more substantially as the schedule gap increases to more than 20. Apparently, for those seeking changes in their hours, they are tolerant of up to 10 additional hours, but not more. Among those not seeking to change their hours, the schedule gap was not significant whatsoever.

Table 5. The Schedule Gap Effect (Hours Worked-Hours Preferred)

Hours worked – Hours Preferred ref: 0Seeking to change hours p = value <0.0001
≤ -1ns
[1, 10]ns
[11, 20]5.85 times less likely to stay
≥ 2110.99 times less likely to stay
ns = not significant (p = 0.05)

Suggestions for Nurse Managers, Nurse Educators, and Further Research

Addressing the shortages of nurses requires both increasing the supply of new nurses coming into the profession and finding ways to reduce the outflow of experienced nurses already working. This analysis of RNs in Maine suggests there are definite characteristics of the work schedules that can influence a nurse's inclination to stay or leave the profession. This is not simply a question of "overwork," but of matching work schedules and hours as closely as possible to employee expectations. Seeking to change the hours of work is a statistically significant precursor to considering staying/leaving the nursing profession when there is a gap between the "contracted" hours or the preferred hours to which the nurse wants to change and the hours they are presently working.
This suggests management needs to find a way to pay attention when nurses request changes in hours. Clearly, the mere fact of changing schedules will not solve the nursing shortage, but it is one action within management's control.
The importance of an attractive work schedule was the focus of a recent study by Wright and Bretthauer (2010). They reported on a hospital scheduling model for nurses that reduced labor costs while also reducing overtime and undesirable shifts. Implementation of the model requires the initial schedule be a coordinated effort between the unit and float pool managers, that the float pool size be sufficient to meet target staffing levels, and that the float pool nurses need to be cross-trained for a selected number of units.
On an individual basis, it is essential that expectations about work hours, including whether the position requires working weekends, nights, and holidays, be discussed at the time of interview, reaffirmed in writing when an offer is made, and discussed routinely as part of performance evaluations. The nurse leader needs to have a clear understanding of the nurse's expectation to determine whether it is realistic. This conversation needs to be ongoing and the process for requesting a change in the number of hours worked needs to be readily available. Once schedules have been set, it is important to minimize changes and, when needed, to consider offering some type of reward to the affected staff members.
Nurse educators also have a responsibility for orienting the future nursing workforce to the work demands of a career in health care. Given the majority of nurses work in hospitals, nursing students need to understand nursing care is required around the clock. Providing clinical education in the evening and on the weekend provides first-hand experience. Encouraging nursing students to work as certified nursing assistants and to participate in internship programs also exposes them to the demands of scheduling. Finally, nursing students need structured practice with interviewing and should be guided in what types of questions they should be asking as they consider their first position as a registered nurse.
The survey of Maine nurses reached a very broad sample, which is one reason why the levels of statistical significance found in the logistic regression analysis conducted here provide noteworthy findings. But the survey was also limited in what it could inquire about with respect to the work environment. Further re search should investigate other aspects of the work environment, and do so in a way that interactions with key variables like work schedules and expectations can be explored. This will likely expand the number of strategies and actions available to nurse leaders that will increase the likelihood of nurses remaining in the profession at least until retirement.


Executive Summary

  • A major question about the adequacy of the future supply of nurses is how many will stay in the profession.
  • The relationship between scheduling and propensity to stay or leave the nursing profession was examined in this study.
  • This analysis suggests there are definite characteristics of the work schedules that can influence a nurse's inclination to stay or leave the profession.
  • This is not simply a question of "overwork," but of matching work schedules and hours as closely as possible to employee expectations.
  • This suggests management needs to find a way to pay attention when nurses request changes in hours.
  • The mere fact of changing schedules will not solve the nursing shortage, but it is one action within the management control of any organization employing nurses that could have a positive effect on retention.


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The authors wish to thank Karen Stefaniak, University of Kentucky College of Nursing, and Robin Kimball, Anil Oztuncer, and Baris Sagiroglu, University Center Graduate Assistants, Maine Center for Business and Economic Research, for their support on this project.

This work was funded through the first author's Robert Wood Johnson Executive Nurse Fellows Program (2000–2003) and through a University Center grant from the Economic Development Administration.
Nurs Econ. 2011;29(3):111-117. © 2011 Jannetti Publications, Inc.